To Operate or Not

You receive a phone call that one of your parents, no longer at “the top of their game,” has fallen in a nursing home. Not only fallen but broken their leg. Without surgery, they will be confined to a bed or chair; with surgery comes an increased risk of dying in the immediate “aftermath” of the procedure. What should you do? A new study considers those issues, which unfortunately are more common than we like to believe.

Here is the question researchers hope to answer

“Is nonoperative management of a proximal femoral fracture a satisfactory alternative for frail patients?”

To answer that question, they looked at patients, age 70 or greater, hospitalized for a fracture of their upper leg between September 2018 and April 2020 who were both nursing home patients and frail. And their definition of frail left no uncertainty. These patients had one or more of the following

  • Body mass of <18.5 indicating malnutrition or cachexia (body wasting due to severe disease or illness)
  • Operative risk based on the American Society of Anesthesiologists of 4 or 5 – the most at risk. A functional ambulatory capacity before the injury that required at least episodic assistance from other individuals

Measures were made of the patient’s quality of health and life by their family and caregivers, along with the use of pain medications, complications, and the usual demographics.

The median age of patients was 88, predominantly women, and slightly more than half of the 172 patients opted for nonoperative management.

  • The 30-day mortality was 83% in the nonoperative group, 25% for those treated surgically. At six months, 94% of the nonoperative group had died, 48% of those undergoing surgery.
  • Pain was greater in the nonoperative group at week 1 (88% vs. 67% in those undergoing surgery), but by week 2, pain levels were essentially the same for both groups. This was reflected in the total mg of morphine they received.
  • Mobility was significantly impaired for both groups. Of the 66 patients that were mobile before surgery, only 29% regained their mobility. 89% of the nonoperative patients failed to recover any mobility and remained bedbound.
  • Measures of health quality were lower for those managed nonoperatively. Still, they failed to fall below the threshold set by the researchers – a reduction in quality of 50% from their already reduced baselines.
  • The use of antibiotics and transfusion were frequent in the surgical group, as might be anticipated.
  • Pressure ulcers were common in both groups 42% in the operative group, 35% in the nonoperative patients
  • Significantly more patients undergoing surgery had adverse events of any kind. Particularly 3-fold more delirium, 4-fold greater incidence of pneumonia, and a 3-fold greater incidence of urinary tract infections.

Pretty grim outcomes. Therefore, it should not be surprising that the researchers could offer no certain recommendations.

“Surgery in these patients is a decisive fix for an isolated problem (the fracture itself), but it is not an intervention that resolves the complex, multifaceted implications of aging and frailty and is not always beneficial to the patient.”

The best they can say is that both operative and nonoperative management should be discussed. Being dropped into this decision as a family member, patient or physician makes for awkward conversations. It is the strongest reason I know that we should all consider these issues before they arise. More importantly, they are a reason you should have a physician with whom you have had a long relationship – that knows you well enough to help you navigate these unhappy choices.


Source: Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients - The FRAIL-HIP Study JAMA Surgery DOI: 10.1001/jamasurg.2022.0089